Assessment of nutritional status in children with acute respiratory failure: the prospective cohort observational study
Pneumonia plays a significant role in the development of acute respiratory failure in children. The risk factors of pneumonia are malnutrition (weight to age relation according to scores), low birth weight ( < 2500 g), and other factors. Regardless of the economic development of countries, the mortality rate in children with pneumonia admitted to intensive care units remains high (18-20%).
Aim. To determine the prevalence of nutritional deficit among patients with acute respiratory failure, taking into account weight to height indices, body mass index to age z-scores, and the visceral pool of proteins according to the level of serum protein.
Materials and Methods. A prospective single-center cohort study (May 2018 - December 2019) was carried out at the Department of Anesthesiology and Intensive Care of the Danylo Halytsky National Medical University in Lviv (Department of Anesthesiology and Intensive Care, Lviv Regional Children’s Clinical Hospital “OCHMATDYT”). Patients aged from 1 month to 18 years old were included in the study. Ethical approval for this study (Ethical Committee protocol N° 1-2018) was provided by the Ethical Committee of the Danylo Halytsky National Medical University in Lviv, Ukraine, on 31 January 2018. The study included 67 patients with acute respiratory failure who required invasive mechanical ventilation during the study. In 7 patients reliable measurement of height was not possible due to significant deformities of the skeleton or severe perinatal injuries of central nervous system; these patients were not included in the data analysis. All patients were divided into groups: 1st group - children aged from 1 month to 1 year; 2nd group - children aged 1 to 3 years; 3rd group - children aged 3 to 5 years; 4th group - children aged 5 to 12 years; 5th group - children aged 12 to 18 years. After admission we evaluated the weight to height and body mass (BMI) indices in relation to age for boys and girls according to the recommended WHO z-scores. Severe acute malnutrition was verified as weight less than “-3 SD” according to the WHO guidelines. Obesity was verified as body mass index over “+2 SD” by age. Level of total protein in serum was obtained and measured spectrofotometrically in blood test samples on the 1st, 3rd, 5th and then every three to five days if total protein level was below 60 g/l. MS Exсel 2017 was used, and the results were presented using frequency (%) and median [IQR] for non-normally distributed variables.
Results and Discussion. Presence of acute severe malnutrition in children with pneumonia is an independent predictor of worsening outcomes. Patients with malnutrition have longer duration of stay at intensive care unit and on mechanical ventilation. The duration of weaning from mechanical ventilation is high and may be accompanied by recurrent episodes of lower respiratory tract infections.Severe acute malnutrition was detected in 23.1% of patients in 1st group (6 patients of 26); in 27.3% in 2nd group (3 patients of 11); one patient in 3rd group (the only patient in this group); 6.3% of patients in 4th group (1 patient of 16), and 16.7% in 5th group (1 patient of 6). Obesity was diagnosed in patients of the 2nd and 4th groups, constituting 18.2% (2 patients of 11) and 6.3% (1 patient in 6), respectively. The findings were analyzed and unidirectional changes in body mass to age and weight to height indices in patients of all groups were identified: the patients included in the analysis were found to have the same level of impairment in both body mass and weight to height indices. To determine the prevalence of changes in total serum protein level, all patients were divided into subgroups of patients with hypoproteinemia below 60 g/l (patients with hypoproteinemia) and patients with total protein levels over 60 g/l (patients without hypoproteinemia). We found that at d1 stage of the study in the 1st group of patients hypoproteinemia occurred in 62.5% (15 of 26), at the d3 stage - in 40% of patients (10 of 26); at the d5 stage - in 20% of patients (5 out of 26). In patients of the 2nd group hypoproteinemia was observed in 36.4% (4 of 11) at d1 study stage; in 18.2% of patients (2 of 11) - at d3 stage. The only patient of the 3rd group had hypoproteinemia at stages d1 and d3. In addition, in the 4th group hypoproteinemia was found in 25% of patients (4 of 16) at the d1 study stage, equally in 6.25% at d3 and d5 stages (in 1 of 16). In the 5th group of patients, these disorders were observed in 33.3% at d1 study stage (2 of 6 patients) and in 16.7% at d3 study stage (1 of 6 patients). Upon evaluation of the dynamics of the total protein level along the study in patients with hypoproteinemia below 60 g/l who were included in 1st and 2nd groups it was found out that total protein level gradually increased from 51.05 [44.12; 56.81] g/l at d1 to 53.77 [49.13; 55,69] g/l at d5 stage, whereas for patients in 2nd group it had a tendency for decreasing from 56,09 [53,05; 57.2] g/l to 53.7 [52.15; 60,38] g/l from d1 to d3 study stage.
Conclusions. Severe acute malnutrition is a common problem in patients with acute respiratory failure with a high incidence in children aged from 1 month to1 year (23.1%) and from 1 to 3 years (27.3%). With age, the incidence of severe acute malnutrition decreased to 6.3% among patients aged from 5 to 12 years and to 16.7% in patients aged from 12 to18 years. A tendency for increasing of total protein level during the first five days of treatment in patients aged from 1 month to 1 year, who had hypoproteinemia at admission, and a tendency of decrease in total protein level in patients aged from 1 to 3 years during the first three days of treatment were revealed.
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